Sixteen Radical Steps to End the AIDS Epidemic

From a special plenary session titled "Looking to the Future -- The Epidemic Steps to End the Epidemic in 2031, and New Directions in AIDS Research" at the XVII International AIDS Conference in Mexico City, August 6, 2008.

Twenty years ago this October, fifteen hundred AIDS activists from around the United States surrounded the headquarters of the U.S. Food and Drug Administration in Rockville, Maryland, to demand that it revolutionize its regulatory approach to the testing and approval of new drugs for AIDS. That demonstration was successful beyond our wildest dreams and we are living with its consequences still. Indeed, I and many thousands of others might not be living today had it not been for the unprecedented activism spawned by the AIDS epidemic over two decades ago.

Ten years ago at the Geneva AIDS Conference, mistitled "Bridging the Gap," I was asked to address the question: "Cure: Myth or Reality?" At that time it was evident that the scientific basis for a cure had not yet been established, despite the recent and revolutionary advent of HAART. In Geneva, I called on AIDS activists, community, leadership, and researchers to work to bring HIV treatment along with better prevention programs to the developing countries where most people with AIDS lived and died. Richard Horton summarized the clinical science news of the conference, and he was excoriating in his criticism of the deep divide he witnessed:

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"This conference was about 'bridging the gap.' So why was it that every day this week, whenever a speaker from a developing world country rose to talk about an issue central to 'bridging the gap,' seats emptied and the halls began to bleed delegates through the aisles and out into the corridors of the conference centre? I watched this happen at least six times to speakers from Africa, India, and Thailand. It was nothing less than shameful.... If you walk out of a room when your own colleagues have travelled long distances ... to share their experiences with you: Why should any government bother to listen if you don't ...?"

Ten years later we are now all working together -- north and south, prevention and treatment, scientists and activists -- in an unprecedented global movement that has radically transformed the outlook for millions of people with HIV, saved millions of lives, and prevented millions of HIV infections. We are more unified than we were in 1998. Infighting is less common than it once was. We have some amazing short-term accomplishments to be very proud of. According to UNAIDS, deaths from AIDS might even have started to fall in the last two years.

But these gains are fragile, may be transitory, and may be undermined by forces viral, demographic, and political. We must not be lulled into slackening of our efforts. Rather, we must intensify our efforts, and overcome the threats that face us.

What is the state of the epidemic in 2008 and where should we be focusing our efforts?

We must seek a cure and a vaccine because lifelong triple-drug therapy for the currently infected will require 990 million patient years of antiretroviral drugs to be manufactured, delivered, and taken by the already infected 33 million -- even if all transmission were somehow magically stopped tomorrow.

Add to this the 2.7 million newly infected each year and over the next 30 years we add another 81 million people who would need lifelong therapy -- barring a cure -- and this will mean another 2.43 billion patient years of ART.

Accelerating scale-up is the foundation for our coming work. We must scale up faster so that we can put one person on therapy for each new infection. But we need massive investment in research on a cure and on better prevention methods if we are ever going to end the AIDS epidemic.

We must strive to continue to lower the numbers newly infected. There are several ways we could dramatically reduce infections rapidly if we are willing to take some radical steps around the world.

Universal treatment for women equals universal prevention for infants
We must ensure that every pregnant HIV-positive woman has access to full antiretroviral therapy (ART) from the time her pregnancy is known to when she completes breastfeeding, and then for life if indicated by her CD4 and health status. And we must ensure that every HIV infected baby is diagnosed at birth and treated for life.

End gender-based violence and strengthen the legal and health rights of women and sexual minorities
We must demand and achieve equal status for women, gay men, lesbians, bisexuals, and transgender people and end the violence against them everywhere.

End the war against sex workers
We must insist on decoupling efforts to stop human trafficking from the current stigmatization and exclusion of sex workers from their full human, health, and economic rights to live and work in dignity, legally and safely.

End the war against drug users
We must end the punitive, expensive, and wasteful global war on drug users. We must work in countries around the world to decriminalize possession of drugs; provide universal access to drug substitution therapy, clean syringe exchange, and safe injecting rooms and equipment; and provide services for people reentering society after being unjustly incarcerated for nonviolent drug use.

End health disparities everywhere
HIV rates among black Americans are eight times higher than those of white Americans; 600,000 black Americans are living with HIV and 30,000 new infections occur among them each year. The epidemic among black Americans is the same size as that in Côte d'Ivoire, and bigger than that of seven priority PEPFAR countries put together.

The U.S. government and its people are obliged to address this epidemic with the same urgency with which they are now addressing the global pandemic.

The United States must develop and implement a national AIDS strategy with specific targets, timelines, and the goal of reversing the epidemic, with special attention and resources targeted toward black Americans, Latino/Latina Americans, women, and men who have sex with men.

Scale up HIV testing and improve HIV epidemiology
We must massively scale up HIV testing globally. New York City has belatedly introduced a policy to test -- voluntarily and with opt-out -- any resident of the Bronx who presents to the health system. If HIV testing can be massively scaled up in Lesotho, it certainly can and should be massively scaled up in New York City, still the epicenter of the U.S. epidemic.

We must have access to much better, more accurate, and timelier information about where the epidemic is and where it is moving to. Recent revisions downward by UNAIDS on the global pandemic and upward by the CDC on the U.S. epidemic have left the impression that we are still far from having a clear enough picture of the size, scope, distribution, and movement of the epidemic in its 28th year.

Define when to start ART
We must continue to accumulate strong evidence about when to start ART. This research is more vital than ever because the public health benefit of scaling up ART depends on maximizing its benefit. For example, starting an appropriate ART regimen earlier for women of childbearing age would likely both benefit the mother and protect the baby.

Given the wealth of information that came from the unexpected results of the randomized SMART study it is urgent that we undertake a long overdue new study of when to start ART.

Prevent, diagnose, treat, and cure TB
Everyone has a responsibility to do a much better job of reducing the impact of TB among people with HIV. HIV clinics around the world must implement infection control procedures, intensified TB case finding, and earlier TB diagnosis and treatment so that no one contracts TB while accessing HIV care.

Routine screening for TB at every clinic visit should also allow healthy HIV-positive persons in pre-ART care to receive cotrimoxazole and isoniazid preventive therapies, which despite overwhelming evidence of efficacy are not routinely used in most sites due to overblown fears about resistance, toxicity, and adherence.

Develop HIV RNA, CD4, and TB point-of-care diagnostics
We need massive new efforts to develop cheap, accurate, and accessible point-of-care diagnostic tests to measure HIV RNA for infant diagnosis, to measure semiquantitative CD4 counts for disease staging and monitoring ART, and to determine whether someone has active TB disease -- either pulmonary or extrapulmonary, among children and adults, whether HIV negative or positive.

Diagnose, prevent, and treat viral hepatitis and common opportunistic infections
We should strive to obtain serology and, when possible, treatment for hepatitis B and hepatitis C infections among HIV coinfected persons. Because of the overlapping activity of certain ARV drugs, we are already treating many people who are coinfected with HBV and HIV without knowing their HBV status. As HBV and HCV treatments mature and oral combination therapy becomes possible, we must be ready to scale up hepatitis treatment globally.

Better opportunistic infection prophylaxis and treatment are also needed. Key drugs must be added to the essential medicines formulary and their prices brought down: amphotericin-B for cryptococcosis, azithromycin for MAC and a host of other infections, rifabutin for tuberculosis, and valganciclovir for CMV retinitis.

Develop better first-, second-, and third-line antiretroviral (ARV) regimens
We still need cheaper, safer, and more durable first- and second-line ART regimens to guarantee the longest possible duration of viral suppression free of side effects. Though the ART treatment space is maturing, there is still room for better combinations with greater durability, less toxicity, higher barriers to resistance, and cheaper manufacturing costs.

Intensify investment in biomedical research, including AIDS research
The last five years have seen stagnation in U.S. investment in research at the National Institutes of Health. The AIDS research budget, nominally $2.9 billion, has lost about 20% of its purchasing power due to inflation during this time. We must demand that the next U.S. president and Congress increase support for all NIH research -- including AIDS research -- by 15% in each of the next five years.

Other rich countries in the European Union and the Organization for Economic Cooperation and Development must double or triple the amount they invest in biomedical research, including research for AIDS, TB, viral hepatitis, and other diseases. Emerging and developing countries need to increase investment in biomedical research five- to tenfold to help address persistent gaps in health research.

Show solidarity with activists, health workers, policy makers, and scientists working on global health issues
We cannot afford a divisive debate that pits advocates for different diseases against each other.

The AIDS movement -- made up of activists, scientists, health workers, and policy makers alike -- has shown that it is possible to scale up antiretroviral treatment to cover three million people in just five years.

Let's make this the vanguard of an unprecedented global citizens' movement for comprehensive universal primary health care for all. We owe it to our colleagues working in TB; malaria; sexual and reproductive health; maternal and child health; and food security and clean water, among many many others, to unite with them to demand the resources necessary to meet and surpass the millennium development goals and to provide not only universal access to HIV prevention, care, and treatment but universal and comprehensive primary health care for all.

Some will say that this is an impossible aspiration. Some of these naysayers said the same thing about ART scale-up in 2000. Some of them do not want to spend rich countries' resources on global health; some, regrettably, are simply jealous of the success of the AIDS movement in mobilizing resources and making an impact. We cannot afford to descend into quarrels with others who genuinely care about global health.

Hold governments accountable to their commitments to health
The 30 richest countries in the world must contribute 0.7% of their GDP to international development. Developing countries must honor their pledge to spend 15% of their national budgets on health. We must reform or abolish the IMF and abolish health user fees, public health sector salary caps, and reduce or abolish burdensome debt. We must commit to spending $50 per person per year on health as recommended by the Commission on Macroeconomics and Health.

Reform the World Health Organization
Sweeping institutional reform is also needed at the WHO. Its antiquated constitution makes it accountable only to member countries and not to the citizens of the world. The regional offices for Europe and for Africa are particularly egregious examples of unaccountable bureaucracies consuming millions of dollars while neglecting the health crises at their doorsteps ranging from drug-resistant TB to HIV and many others. Civil society needs to take a role in WHO governance.

Stay focused and united
Changes in the global health architecture and in the global political context mean that it will become increasingly difficult to maintain the necessary focus on HIV as it continues to rage unchecked and uncontrolled in a world beset by economic turmoil, famine, global warming, and wars. And some will say that AIDS is no longer an emergency.

We need greater unity
We must become more united if we are to become an even more powerful force for global public health, human rights, and social justice, with our goal of universal access evolving into comprehensive and universal primary care for all. To those who say it cannot be done we must reply, "¡Si se puede! Yes, we can!"

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